Position Title: Healthworks ACT Case Manager
Position Classification: Full Time, Non-Exempt
Programmatic Supervision: Healthworks Social Work Service Line Lead
Organizational Supervision: Director of Services for Groundworks
Employed Organization: Groundworks Collaborative
Fiscal Sponsor for Healthworks: Brattleboro Memorial Hospital
Worksite: Healthworks ACT Office in Brattleboro with outreach in the community
Work Hours: Monday to Friday, daytime, with rotating on-call responsibilities
Compensation: $19.72 to $24.69, Hourly, Tier 2 (FY24 Pay Scale)*
Benefits: Groundworks is proud to offer excellent benefits (valued at over $19,000) to our employees - https://tinyurl.com/GW-Benefits-Package
Including 100% coverage by Groundworks of Employee's Individual Health Insurance Premium and Deductible.
*Pay offers will be determined based on a skill & competency based self-evaluation and hiring manager’s evaluation of readiness to perform in the role. This is a highly transparent and explicit process that supports compensation around experience and skills and takes the guesswork and opaqueness out of the typical offer processes.
About Groundworks Collaborative
Established in 2015, following the merger of the Brattleboro Area Drop-In Center and Morningside Shelter, Groundworks is a dynamic organization committed to providing food, shelter and supportive services with dignity throughout the greater-Brattleboro area.
Groundworks’ mission is to work with individuals and systems to create solutions for ending hunger and homelessness for all people in our region. We envision a community in which all members have their basic needs met, including food security and a safe and dignified place to call home. We view poverty, housing and food insecurity to be byproducts of societal conditions, generational discrimination, and public policy, rather than the result of individual choices. Therefore, Groundworks fosters a culture of nonjudgement and compassion for the people we serve.
HEALTHWORKS PROGRAM SUMMARY
The Healthworks Assertive Community Treatment (ACT) team, a joint project of Groundworks, Brattleboro Memorial Hospital, The Brattleboro Retreat and HCRS, is a participant-led approach to improving care and outcomes for people who are experiencing homelessness or housing insecurity in Windham County. ACT is an intensive, integrated services and support model designed for people whose basic needs are not being met by existing housing, medical, and mental health services. The Healthworks ACT team is designed to deliver integrated services of the participants' choice, assist in making progress towards goals, and adjust services over time to meet participants' changing needs. The staff-to-participant ratio is small, and services are provided 24-hours a day, seven days a week, for services as they are needed.
The Healthworks team will be adaptable, promote access and have strong communication skills, not only with participants but with the team and community (ex. shelter milieu, tent sites,hotels). Healthworks ACT team members are expected to provide outreach to community members, who are enrolled in the ACT program and/or who are served by Groundworks. The team will value and advocate for physical and mental health access and autonomy, through an equity and justice lens, for all participants.
Position Summary
The Case Manager is responsible for working closely with clients to help them secure and maintain housing, and access services to meet their basic needs and contribute to their well-being. Case managers provide referrals and create robust community networks to ensure clients can successfully access additional support.
Effective case management starts with building an authentic, trust-based relationship with each client. The Case Manager then assesses individual needs, and works with each client to co-develop a plan for meeting the needs identified by clients. The Case Manager
maintains robust and current knowledge of community resources and builds collaborative relationships with community service providers to ensure effective referrals and seamless access to support. This position is embedded within the larger Healthworks ACT Team, that includes healthcare and mental health professionals.
Case managers utilize creative problem solving and a person-centered, harm reduction approach, while modeling Groundworks’ philosophy of dignity and respect at all times.
This position is primarily community based with an office space on the South Main Street campus.
Responsibilities
Engage and support Clients (75%)
Engage Clients
Build Client Rapport
- Build trusting client relationships and provide services from a client centered, harm reduction, and strengths-based approach in order to meet individualized client needs.
- Demonstrate Groundworks’ and Healthworks’ philosophy, mission, values and standards of excellence.
- Maintain client confidentiality within Healthworks guidelines.
- Solicit client feedback to identify improvement opportunities.
Assess Client Needs
- Engage individuals in meaningful dialogue in order to mutually assess their needs.
- Identify housing barriers, needs/preferences; explore resources and opportunities within a household's natural support network.
- Complete Coordinated Entry assessments; make referrals to area providers when appropriate.
Co-create a Housing and Service Plan
- Work with clients to develop an action plan for locating housing, including specific goals, timeframes, and action steps to address barriers to housing stability.
- Remain in regular contact with clients and provide compassionate, nonjudgmental, person-centered and responsive services.
- Collaborate with clients to formulate and maintain a service plan that addresses non -housing service needs and goals which is reviewed and modified with the client on a bi-weekly basis.
Support Clients’ Basic Needs
Support Clients in Accessing Other Services
- Provide appropriate services and referrals to connect clients with mainstream services and benefits (e.g. 3 Squares, GA, SSDI), including access to state benefits where eligible.
- Support clients in obtaining identification (e.g. state issued ID, SSA card, birth certificate)
- Support care coordination with Healthworks team healthcare providers
- Educate, inform and advocate for clients regarding benefits (Social Security, Public Assistance, food stamps, etc.).
- Support clients in creating a case plan, with goals focused on self-determination
- Complete applicable ROI’s, assessments, as well as ongoing case notes
Provide 1:1 Support
- Performing ongoing, individualized support and coordination for clients.
- Coordinate and monitor referrals to community services, and advocate for client participation.
- Respond to acute and crisis situations in a timely manner during operating hours, including coordination with emergency service providers.
- Practice skillful de-escalation and crisis management.
- Support clients in finding employment, including referring to employment assistance agencies.
- Support clients in addressing or mediating interpersonal conflicts if needed
Support Clients’ Housing Needs
Support Clients in Accessing Housing
- Develop a budget based upon analysis of income and expenditures; discuss housing options.
- Work to address housing admissions barriers (e.g. criminal record, credit report, utility arrears).
- Assist clients in addressing credit issues.
- Conduct housing searches and assist with locating housing that is safe and move-in ready.
- Assist clients in navigating the housing path including viewing units, completing long term housing applications, understanding leases, and landlord negotiations.
- Assist in arranging for/supporting move (set up utilities, moving arrangements, etc.).
- Find resources to support move in (e.g. security deposit, moving costs, furnishings, etc.).
- Provide education and training on the role, rights and responsibilities of the tenant and landlord.
- Develop a housing crisis support plan (prevention/early intervention) if housing is jeopardized.
- Identify other service needs/ongoing retention support needs and connect clients to those services and benefits.
Support Clients in Retaining Housing
- Coach on developing and maintaining key relationships with property management/landlords with a goal of fostering a successful tenancy.
- Assist in resolving landlord/neighbor disputes to reduce risk of eviction or other adverse action.
- Advocate and link with community resources to prevent eviction when housing is, or may potentially become jeopardized.
- Assist with housing and voucher recertification process.
- Coordinate with tenant to review, update and modify their housing support plan on a regular basis to reflect current needs and address existing or recurring housing retention barriers.
- Continue training on being a good tenant, lease compliance, and provide ongoing support related to household management.
Build Collaborative Relationships and Resources (7%)
- Maintain robust knowledge of relevant community resources throughout the county.
- Regularly explore new or unfamiliar resources to remain current.
- Build relationships with community service providers in order to make effective referrals.
- Ensure current community resource information is on hand at all times.
- Share information with colleagues from other area support agencies to enable ongoing capacity building and collaboration that serves client needs optimally.
- Maintain collaborative relations with other professional service providers for the purpose of case review or consultation regarding services to a specific client.
- Collaborate with other agencies to assist with other needs that are presented.
- Collaborate with other groups and agencies as a representative of Groundworks Collaborative.
Manage Case Files and Data (5%)
- Document all services and activities in case files. Ensure files are up to date and complete, including Case plans, ROI, service transactions, case notes, and referrals.
- Enter complete data into CERNER.
- Follow the critical incident policies and procedures; complete incident reports.
- Comply with the State of Vermont’s Mandated Reporter duties.
- Participate in case transfer of services when appropriate. Close out case files when clients’ needs are met or clients no longer request services.
Promote Teamwork and Excellence (13%)
Demonstrate Personal Accountability
- Demonstrate personal ownership and initiative in problem-solving.
- Hold oneself accountable to high performance standards.
- Take advantage of training opportunities. Attend and participate in a variety of training and continuing education events to remain current and enhance knowledge and skills.
- Participate in regular team meetings.
- Participate in weekly/bi-weekly individual supervision. Discuss with supervisor successes and challenges, improvement areas, performance goals, and areas for growth and learning.
- Uphold and maintain Groundworks’ values and foster Groundworks’ service mission and culture of understanding, compassion and positive regard for clients.
Cultivate Teamwork
- Participate in building a team culture of collaboration and shared ownership.
- Share relevant information and updates with appropriate teams.
- Support team goals and collaborative problem-solving.
- Build effective working relationships and collaborate with team members.
- Support case management team members as needs arise.
- Practice giving and receiving skillful, respectful feedback to coworkers when issues come up.
Promote Agency-wide Success
- Attend and participate in All-Staff meetings.
- Contribute to agency-wide learning and problem-solving, coordination and communication.
- Support the seamless coordination and integration of Groundworks’ and Healthworks’ programs and services.
Embrace Diversity, Equity and Inclusion
- Practice curiosity and openness to diverse backgrounds, experiences and ways of thinking.
- Build skills and understanding of anti-racist and anti-oppression frameworks.
- Foster mutual aid vs. charity and strive to understand the systemic and root causes of poverty.
Competencies
Passion and Mission
- Passion for the mission: ending homelessness and ensuring food security for all people.
- Passionate about community-based work.
Understanding and Insight
- Insight into homelessness root causes, challenges related to poverty, addiction, mental health.
- Robust knowledge of housing, resources, and systemic barriers; effectively navigates services.
- Embraces a harm reduction approach and embodies compassionate, nonjudgmental care for all.
Community Engagement and Advocacy
- Deep knowledge of the community and strong skills in community outreach and advocacy.
- Builds authentic and trusting relationships with clients; maintains high confidentiality standards.
- Skillful and empathic listener; connects well with others and listens for understanding.
- Works well independently and effectively with all team members; asks for help when needed.
Problem-Solving and Initiative
- Solution-oriented, takes initiative and engages others in thoughtful problem-solving.
- Reads people and situations effectively, exercises solid judgment and critical thinking.
- Works through complex, challenging situations utilizing creative problem-solving and a person-centered, harm reduction approach while balancing agency policy.
Positive Attitude and Ownership
- Has a positive, can-do attitude; takes ownership and pitches in wherever needed.
- Models excellence, holds self/others accountable and responsible for ensuring quality services.
Communication and Teamwork
- Demonstrates extreme reliability, takes initiative and can work well without direct supervision.
- Excellent written and interpersonal communication skills that foster a team environment.
- Collaborative and cooperative team-player; seeks others’ ideas and input.
Flexibility and Adaptability
- Is flexible, adapts quickly to change, responds to unpredictable events quickly and effectively.
- Finds the most efficient and effective ways to work, builds and enhances systems.
Professionalism and Self-awareness
- Is timely in reporting to work, fulfilling commitments, and responding to emails/calls.
- Embraces continuous learning and actively participates in ongoing professional development.
- Is self-aware, reflective, curious, open to feedback. Understands own strengths and weaknesses.
- Self-regulates emotions, chooses words with care; responds skillfully in stressful situations.
- Remains calm under pressure, de-escalates, mediates; handles challenging situations with grace.
- Exhibits effective stress management, self-care, limit-setting, resilience, and a sense of humor.
Diversity, Equity, and Inclusion
- Embraces diversity, equity, and inclusion, is culturally competent, works well across differences.
- Shows awareness of one's own culture, identity, biases, prejudices, and stereotypes.
- Appreciates and embraces a variety of experiences and perspectives which arise from differences in race, culture, religion, age, gender, sexual orientation, ability, and gender identity.
Administrative and Technical Skills
- Is knowledgeable of agency standards, protocols, policies, and systems.
- Is resourceful in finding solutions, addressing challenges, and seeking opportunities.
- Exceptional computer skills including data management programs.
- Has a valid driver’s license and registered, insured, and reliable vehicle.
Qualifications
Education:
- BA in Human Services, Social Work, or related field required, or significant & comparable professional experience.
Experience/skill set:
- 2-5 years of experience working with vulnerable populations required, triage/crisis experience preferred.
- Specific training and/or education regarding substance use disorder and/or psychiatric care.
Licensure/Certifications:
- Valid Driver’s License, and registered, insured, and reliable vehicle required.
Additional Preference:
- While this position does not require it, an applicant with lived experience of homelessness will be received favorably.
- Experience working in a medical/clinical setting and collaborating with healthcare providers preferred.
- Master of Social Work or other advanced degree in Mental Health.
Job Type: Full-time
Pay: $19.72 - $24.69 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- 401(k) matching
- Employee assistance program
- Health insurance
- Health savings account
- Life insurance
- Paid time off
Schedule:
- 8 hour shift
- Monday to Friday
Work Location: In person